The Advanced Colon Bundle - NYSPFPApr 02, 2014 · COLO SSI Standardized Infection Ratio . by Year...

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

The Advanced Colon Bundle

April 2, 2014

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NYS PARTNERSHIP FOR PATIENTS

Agenda

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TOPIC SPEAKERS I. Welcome and Introductions Wing Lee, Project Manager, NYSPFP

II. Introducing the Advanced Colon Bundle

Wing Lee, Project Manager, NYSPFP

III. Surgical Site Infection Reduction Efforts: What It Means in 21st Century Healthcare

Robert R. Cima, MD, MA Professor of Surgery, Mayo Clinic

IV. Hospital Gap Analysis Maria Sacco, Project Manager, NYSPFP

V. Hospital Discussion and Question and Answer

Facilitated by Maria Sacco, Project Manager, NYSPFP

Advanced Colon Bundle

March 31, 2014 3


No Harm Across the Continuum of Surgical Care P

re-O

pera

tive Pre-admission

preparation Preoperative bathing Antimicrobial prophylaxis Normothermia ADE – medication reconciliation Patient education

Intra

-ope

rativ

e Glucose control Normothermia Weight-based Antimicrobial Re-dosing Pressure ulcer prevention Brief, debrief, checklists

Pos

t-ope

rativ

e ADE – pain control VTE prophylaxis Foley catheter removal Fall prevention Pressure ulcer prevention Patient and family caregiver information on wound care


Why Focus on Colon Surgical Site Infections?

5

o 2.6% of 30 million operations per year are complicated by SSI (800,000 – 2 million SSI annually)

o SSI accounts for 38% of HAI in surgical patients o Colorectal surgery SSI rate varies between 5% to 30% o SSIs are associated with:

o Increased length of stay o Increased hospital costs (estimated increase of $1,300 –

$5000 per case) o Increased patient morbidity, and mortality o Increased readmissions rates1-5

References: 1. Boyce JM, Potter-Bynoe G, Dziobek L. Infect Conrol Hosp Epidemiol. 1990; 11(2):89-93 2. Poulson KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. Epidemiol Ifect. 1994; 113(2); 283-295 3. Martone WJ, Jarvis, WR, Culver DH, Haley RW, Bennet JV, Brachman PS, eds. Hospital Infections. 3rd ed. Little, Brown & Co. 1992:577-596 4. Vegas, AA, Jodra VM, Garcia ML. Eur J Epidemiol. 1993;9(5):504-510 5. Murray BW, Huerta S, Dineen S, Anthony T. J Am Coll Surg 2010;211(6):812-822


NYSPFP Colon SSI SIR

March 31, 2014 6

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

CO

LO S

SI S

tand

ardi

zed

Infe

ctio

n R

atio

Year and Month

COLO SSI Standardized Infection Ratio by Year and Month

COLO SSI Standardized Infection Ratio Baseline Comparison

27% Increase

SSI-Colon Surgery Standardized Infection Ratio (SIR) All NHSN-Reporting Hospitals Nationally (n = 3,308)

SSI – Colon Surgery SIR

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National SSI-Colon Surgery Standardized Infection Ratio (SIR), Current Rate and Percent Improvement by HEN


High Performance in NYS

10

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

SSI

Col

on S

urge

ry S

IR

SSI Colon Surgery Standardized Infection Ratio (SIR) Top 75% of Hospitals Performing for Sep-Nov 2013 (n=90)

SSI Colon Surgery SIR Baseline Comparison

18.7% Improvement


Bundle Elements

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Normothermia Glucose Control

Antimicrobial Prophylaxis

Increased Peri-operative Oxygenation

Skin Preparation

Clean Standardized Fascia Close

Wound Management


Flowchart is available for download from https://www.nyspfp.org/Members/Initiatives/InfectionPrevention/SSI/Tools.aspx


Bundle Elements

13

ESSENTIAL BUNDLE ELEMENT

STRATEGIES FOR APPLICATION OF BUNDLE ELEMENT

Normothermia Maintain core temperature > 36°C during the perioperative period

• Standardize warming interventions and protocols in both the pre-operative holding area, OR, and PACU.

• Active warming of patients (e.g., Bair hugger) in the holding area to reduce risk of inadvertent hypothermia for patients with temperature ≤ 36°C.

• Check temperature prior to entering the operating room. Check every 15 minutes intra-operatively. Check immediately upon arrival in PACU and every 30 minutes until discharge from PACU.

• Use of warmed IV fluids in the OR Glucose Control Maintain blood glucose level < 200 mg/dl on the day of surgery and through the postoperative period

• Establish glucose control protocols for use throughout peri-operative operative process.

• Identify known diabetics and potential hyper-glycemics in the PAT. Work with endocrinologist to reduce HbA-1C for known diabetics.

• Frequent monitoring of blood glucose (all patients, both known diabetics and non-diabetics) beginning in the pre-operative holding area, in the OR, in the PACU, and on all units. Institute glucose management protocol (e.g. Basal bolus or standard protocol insulin delivery for blood glucose > 200 mg/dl. )


Bundle Elements (Cont.)

14



Antimicrobial Prophylaxis Maintain therapeutic levels of the prophylactic antimicrobial agent in serum and tissues throughout the operation, using weight-based dosing and re-dosing as appropriate.

• Standardize prophylactic antibiotic protocols, with additional guidance on weight-based dosing and re-dosing for long cases based on the half-life of the selected antibiotic.

• Administer weight-based antibiotics within 1 hour prior to surgical incision. (N.B. Vancomycin or a fluoroquinolone should be administered within 60-120 minutes before the initial incision due to the longer infusion time of these antimicrobials).

• Re-dosing for long cases based on half-life of drug used or when there is excessive blood loss.

• Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery).

Increased Perioperative Oxygenation Maintain optimal tissue oxygenation throughout perioperative period by administering supplemental oxygen at intra-operatively and post-operatively

• In patients with normal pulmonary function administer increased FiO2, (i.e.., up to 0.80 FiO2) intra-operatively and post-operatively while in PACU or for 2 hours in the receiving unit, in combination with strategies to optimize tissue oxygenation through maintenance of perioperative normothermia and adequate volume replacement.


Bundle Elements (Cont.)

March 31, 2014 15



Skin Preparation Use an antiseptic agent with alcohol for skin preparation unless contraindicated

• Use chlorhexadine gluconate with isopropyl alcohol or iodine povacrylex with alcohol (70%) to prepare skin prior to surgery.

• Allow skin to dry completely prior to application of adhesive drapes to ensure good adhesion and to reduce fire risk.

• Standardize processes for hair removal prior to surgery. If hair removal is required, use clippers. (N.B. razor or depilatory creams should not be used.)

Clean Standardized Fascia Close Change gown, gloves, and surgical instruments for closure of fascia

• Surgeon announces time to close to indicate necessity for change of gowns, gloves, and closing trays.

• Ensure clean closing trays and instruments are available for closing of fascia. • Standardize closing of abdominal wound (e.g. with a subcuticular closure

except type IV cases, where skin is left partially open). Wound Management Standardize wound management strategy for all types of colorectal surgeries.

• Standardize intra-operative application of wound dressing to reduce risk of contamination and maximize wound healing.

• Standardize post-operative wound dressing, such as continuation of wound dressing for 24-48 hours and dressing removal on POD 2.

• Instructions for cleansing agent use based on open or closed status of wound.

• Provide patient and caregiver education on optimal post-discharge wound care.


16 Bundle Summary Table is available for download from https://www.nyspfp.org/Members/Initiatives/InfectionPrevention/SSI/Tools.aspx

©2014 MFMER | slide-17


Surgical Site Infection Reduction Efforts What It Means in 21st Century Healthcare

Robert Cima, MD, MA New York State Partnership for Patients

April 2014


How Does One Define Quality • 1) a: peculiar and essential character b: an inherent feature; c: capacity,

role

• 2) a: degree of excellence; b: superiority in kind

• 3) a: social status; b: aristocracy

• 4) a: a distinguishing attribute : characteristic; b: an acquired skill: accomplishment

• 5) the character in a logical proposition of being affirmative or negative

• 6) vividness of hue

• 7) a: timbre; b: the identifying character of a vowel sound determined chiefly by the resonance of the vocal chambers in uttering it

• 8) the attribute of an elementary sensation that makes it fundamentally unlike any other sensation

• http://www.merriam-webster.com/dictionary/quality


Defining Quality Healthcare • The degree to which health services for individuals and

populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

• Institute of Medicine; Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

• The Six Aims of Quality Healthcare • Safe: Avoiding preventable injuries, reducing medical errors • Effective: Providing services based on scientific knowledge (clinical guidelines) • Patient centered: Care that is respectful and responsive to individuals • Efficient: Avoiding wasting time and other resources • Timely: Reducing wait times, improving the practice flow • Equitable: Consistent care regardless of patient characteristics and demographics


Stakeholders in Surgical Quality


Traditional View of Surgical Quality

Surgical Skill (Implied)

Patient Risk Factors

Outcome

Modified from Vincent et al. Ann Surg 2004


21st Century View of Surgical Quality A Surgical “System of Care”

Patient Factors

Surgical team Procedures

Operative events Communication Technical Skills

Team Performance Decision-making

Operative environment

Operation Profile

Medical Services Nursing Services

Pathology Services Radiology Services

Hospital Infrastructure Communication

Information Processing/Technology

Hospital Profile Outcome

Modified from Vincent et al. Ann Surg 2004


Essential Healthcare Quality Improvement Concept • Health care outcomes are the result of an

interaction between natural and health care delivery processes

• Common cause variation • Phenomena constantly active within the system • Variation predictable • Irregular variation within an historical experience base • Lack of significance in individual high or low values

• Special cause variation • Stems from external sources that influence the process


The Role of Complexity in Surgical Outcomes • Colorectal Surgical Site Infections (SSIs) result

from an interaction of numerous factors.

SSI

Patient Factors •Weight

•Smoking •Diabetes

•Heart disease •Genetics

•Age •Gender

Disease Factors •Cancer

•Inflammatory bowel disease

•Infectious diseases •Immunosuppressed

states •Chemo/XRT

Treatment

Surgical Factors •Emergent v Elective •Laparoscopic v Open

•EBL •Wound classification

•Site of resection and type of anastomosis

•Case duration •Fluid status

•Body temperature •Surgeon experience • Team experience

•


SSI Reduction Efforts • Facts:

• Numerous elements contribute to SSI development • Relative contribution of each element to SSI

development is unknown • The influence of each element to SSI development is

not constant • SSI occurrence for an individual patient is unpredictable

• Conclusion • No single intervention will have a significant impact on

SSI


The Role of Complexity in Changing SSI Outcomes

Multiple Contributing

Factors

A Single Intervention

No Impact on SSI


Complexity, Quality Improvement, and SSI Reduction • In any complex system, successful QI requires

reducing process variation as much as possible

Diversity is good for creativity Uniformity leads to predictability, improved process control, and more predictable outcomes


The Beginnings of SSI Reduction Process Improvement • Multi-disciplinary team

• Multiple contributing factors need multiple experts to understand how we can address these factors

• Define the Current State across the Entire Process

• What is current performance? • What is/are the current process(es)?


SSI Reduction Process Improvement Effort • Construct a Value Stream Map (VSM) of the

processes across the episode of care • Identify steps/interventions that can add “value” to

the outcome • Known interventions that are associated with SSI

reductions • Appropriate, weight based antibiotics administered at the

correct time • Possible interventions that might contribute to reducing SSI

if they are • Easily placed into the system • Can be done with high compliance • Make economic sense


What Does Process Improvement for SSI Reduction Really Mean • Gain consensus on those VSM elements that all

stakeholders agree to implement • Design processes to ensure a high level of

compliance with each implementation element • Actively monitor compliance with the process

steps and provide feedback on compliance • Long and short:

• Develop a “bundle” of interventions and make sure everyone does what they are suppose to do


Why is Surgical QI Difficult for Surgeons? A perspective problem

Surgeons tend to be very focused


Mayo CRS SSI Reduction Effort


Process Improvement Approach

DMAIC Method: process improvement based upon a Lean/Six Sigma approach

Improvement cycle

D M A I C

Define Measure Analyze Improve Control Project

selected by sponsor

Project either closed or transitioned to operational owner


“As Expected” in NSQIP CRS SSI

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Pro

porti

on

05/2

006

07/2

006

09/2

006

11/2

006

01/2

007

03/2

007

05/2

007

07/2

007

09/2

007

11/2

007

01/2

008

03/2

008

05/2

008

07/2

008

09/2

008

11/2

008

01/2

009

03/2

009

05/2

009

07/2

009

09/2

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11/2

009

01/2

010

03/2

010

05/2

010

07/2

010

Month/Year

0.088

LCL=0.000

UCL


Mayo Bundle


Improvement Phase Results

Jan-12Sep-11May-11Jan-11Sep-10May-10Jan-10Sep-09May-09Jan-09

0.4

0.3

0.2

0.1

0.0

Month and Year

Prop

orti

on

_P=0.0388

UCL=0.1837

LCL=0

2009 2010 2011

Tests performed with unequal sample sizes

P Chart of Total Observed SSI by Phase


SSI Reduction in Colorectal Surgery • SSIs in colorectal surgery is a complex, multi-

factorial problem • Reduction efforts require multiple intervention

across the surgical episode • Development of a “bundle” of interventions will

help to reduce variation • Stakeholder buy-in is essential • Designing into the system of care is essential

ensure compliance • Monitoring compliance is essential

Gap Analysis

Maria Sacco, NYSPFP


Gap Analysis

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March 31, 2014 41

Hospital Discussion and Question and Answer

Next Steps


Next Steps o Complete Gap Analysis o Recruit appropriate team members to attend in

person session: o May 5 - Syracuse o May 6 - NYC o For more information and to register visit:

o https://www.nyspfp.org/Members/myCalendar.aspx

The Advanced Colon Bundle - NYSPFPApr 02, 2014 · COLO SSI Standardized Infection Ratio . by Year...

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